Is postmenopausal bleeding normal?

Anthony L. Komaroff, MD
Internal Medicine
A woman is "in menopause" after she has gone for one full year without periods. So postmenopausal bleeding is any vaginal bleeding that occurs after this time. It is more common in the first one or two years of menopause. It falls off quickly to affect about 4% of women after three years.

A doctor needs to know about any postmenopausal bleeding to exclude the possibility of uterine cancer or hyperplasia, a precancerous condition. Fortunately, cancer is the cause of postmenopausal bleeding in only about 10% of women who have this symptom.

An evaluation of postmenopausal bleeding begins with an exam of the vagina and cervix to see if the blood is coming from the lower genital tract. A pelvic ultrasound is often used to check the internal organs, including the uterus, Fallopian tubes and ovaries.

The width of the uterine lining (the endometrium) is measured during the ultrasound. It should be quite thin after menopause. That's because estrogen levels are too low to stimulate growth of this tissue. If the endometrium is thick, a biopsy is used to gather cells that will be inspected under a microscope. This can determine if cancer or a noncancerous (benign) process caused the thickening.

In women not yet in menopause, estrogen is secreted by the ovaries each month to prepare the uterus for pregnancy. Estrogen levels rise in the first two weeks of a menstrual cycle to stimulate the growth, or proliferation, of the endometrium. If a pregnancy does not occur, the endometrium sheds as the menstrual period.

After menopause, the production of estrogen slows and eventually stops. Since this is a gradual and sometimes irregular process, proliferative endometrium may still be found in early menopausal women. Proliferative endometrium is a noncancerous (benign) and normal cause of thickening seen on an ultrasound.
Barbara J. Depree, MD
OBGYN (Obstetrics & Gynecology)
Postmenopausal bleeding is never considered 'normal', saying that, it doesn't necessarily mean there is any serious issue going on either, but an evaluation is necessary to determine the possible causes. Twelve months without a menstrual period is the definition of menopause, any bleeding that occurs beyond that 12 months would be considered postmenopausal bleeding. A careful history is obtained reviewing the nature of the bleeding, duration, intervals of occurrence, association with any activity (eg. intercourse), medication review. Then a careful exam is carried out to inspect the vulva, vagina, cervix and palpate the uterus and ovaries. Bleeding could come from any of these areas. An endometrial biopsy is often very helpful to determine the cellular composition of the lining of the uterus. If there is thickening of the endometrium it may be entirely benign, or caused by a polyp, precancer or cancer.  An endometrial biopsy is helpful in determining if any of these conditions exist. The biopsy is an office procedure where a thin (2-3 mm) instrument is inserted thru the cervix into the uterus to collect the cells (a pap smear does not assess the uterine lining.) If a biopsy is not possible, a pelvic ultrasound can be helpful to visualize the pelvic organs, measure the thickness of the endometrium and determine if there are any concerns based on this.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.